Treating elderly people with multiple complex medical and social problems is one of the more challenging areas of our work. The goal is to work as part of a team to maintain the persons dignity and autonomy, while pacifying anxious relatives and navigating through the bureaucracy that is the NHS and social services. Elderly patients are often fantastically appreciative and working with them can be extremely rewarding. Having said all that, it is bloody hard work!
I worked once in a city practice in a young trendy part of town. There simply werent many elderly people who lived there. I saw more patients in less time and didnt do any home visits. I had less disease targets to worry about because few of my young patients had chronic conditions such as heart disease and diabetes. I sat in a trendy coffee shop during my lunch hour, while my GP colleagues around the country traipsed round nursing homes and arranged home helps and hospital admissions. My job was certainly easier but also less rewarding and less interesting.
I recently read that Harold Shipmans murders were motiveless. I dont think they were. Most GPs could think of several frail, vulnerable elderly patients who take up a lot of their time. Shipman murdered his. One of the hardest parts of being a GP is taking care of elderly people wanting help for untreatable degenerative diseases. Most of us find that listening and offering some practical support and advice is the best we can do and actually very much appreciated. Shipman clearly viewed things differently and felt it was his right to murder his elderly frail patients. I imagine he enjoyed the power but I also think he was motivated by reducing his workload.
Bums
Intimate examinations can be awkward for both doctor and patient. Fortunately, a good explanation and reassurance from the doctor can make the whole procedure a lot less difficult. When the patient doesnt speak very much English, the situation can be that bit more uncomfortable. This was the scenario I faced with Olga, a young Bulgarian woman who came to see me.
Pain in bottom, Doctor, she said in a very broad Eastern European accent.
I began to ask a few questions about what sort of pain it was. Was it related to going to the toilet? Was there any blood in the poo? These are all the normal questions that would usually give a doctor a fairly good idea of what the diagnosis might be. The problem was that each question was met with blank confusion. Olga had clearly found out how to say pain in bottom but was unable to understand any word I said. Despite a brilliant attempt on my part to mime diarrhoea and constipation using a mixture of diagrams, sound effects and facial expressions, I was getting nowhere. Feeling completely useless, the only option I had left was to examine her. I motioned towards the couch and mouthed out the word EXAMINATION very slowly and loudly. Olga seemed to understand, so I pulled round the curtain to give her some privacy as she undressed.
As those of you who have had the misfortune to have had your bottom examined by the doctor will know, we generally expect you to drop your trousers, jump up on the bed, pull your knees up to your chest and lie on your side facing away from the doctor. I usually have a blanket handy so the patient can remain covered until the examination itself takes place. Normally, the whole ordeal is quick and relatively painless well, painless for me, anyway. Unfortunately, it would appear that things are done slightly differently in Bulgaria. I pulled back the curtain to find Olga naked from the waist down leaning over the couch with her bottom pointing to the ceiling. No no, you need to be up on the bed! I cried. ON THE BED, I repeated slowly and loudly. I pulled the curtain across again and after a few polite moments went back in. This time Olga was on all fours on top of the couch still with her bum pointing up in the air. After much gesticulating and loud slow explanations, I was still no closer to having Olga in a position in which I could examine her. I motioned for her to get off the bed and got on myself lying in the correct position. LIKE THIS, YOU SEE. I was lying curled up on the bed while my half-naked patient was standing beside me still looking very puzzled. It was a moment that I was very glad wasnt interrupted by a receptionist bringing in a cup of tea.
I did finally manage to examine Olgas bottom, only to find nothing unusual at all. In theory I should have done a rectal examination as well, but poor Olga had faced enough already and inserting my finger up her back passage without her really being able to understand my explanation of what I was doing seemed a bit unfair, bordering on abuse. I managed to book her in for an appointment another time with an interpreter present but she didnt turn up, possibly having somewhat lost faith in me.
I recall another difficult rectal examination back when I was an A&E doctor. An elderly lady called Ethel had been brought in by her husband, Lionel, because of her having some tummy pains and bleeding from her anus. Ethel herself was quite demented and also very deaf. Lionel was a retired vicar and now caring for Ethel full time at home.
After taking a history from Lionel and feeling Ethels tummy, I needed to do a rectal examination. It was important to make sure that there wasnt a blockage in the rectum causing her symptoms. I'm going to need to examine your rectum, Ethel. You what, love? I can't hear you. I need to put a digit up your back passage, Ethel, I say again a bit louder and into her good ear. Whats he saying, eh? IM GOING TO HAVE TO PUT A FINGER UP YOUR BOTTOM. This time I was shouting at the top of my lungs. It was only a set of curtains that separated us from the rest of the A&E department and, as you can imagine, curtains arent particularly soundproof. The entirety of the A&E department was now aware of Ethels impending rectal examination but, unfortunately, Ethel wasnt. Her confusion was such that she couldnt really comprehend what I was doing or why. Despite my best efforts to put her at ease, she was getting increasingly agitated. I put on a pair of gloves, moved her into as comfortable a position as possible and gently eased my right index finger into her anus. Suddenly, there was an almighty shriek. Oooh, Lionel. Stop it, Lionel. You know I dont like it that way. If youve got to put it in, at least put it in around the front. Poor Lionel was standing outside the cubicle in full view of all the patients and staff who were trying to hold back their giggles. He looked very embarrassed as he made his way back into the cubicle.
Julia
Julia was young, attractive and articulate.
I need you to section my boyfriend Andy. Hes completely mad and unreasonable and yesterday he smashed up my moped for no reason.
I wasnt expecting that one.
Your boyfriend doesnt sound very nice but we arent going to be able to section him.
But hes mad! It wasnt just any moped. It was my twenty-first birthday present. I drove it everywhere. It was my most precious possession! He knew that!
I was tempted to explain that there wasnt a special subclause in the Mental Health Act that allowed us to section people if the moped they smashed up was a very special birthday present. I held back and instead explained how a person would need to have a mental disorder and pose a risk of harming themselves or others before they could be sectioned.
He is a risk to me. He beats me up! Julia then proceeded to lift her shirt to reveal an impressive array of bruises on her torso.
Why dont you leave him? There is a local domestic violence support group. Perhaps I could
Julia interrupted me. He needs me. He says he would kill himself if I left him and I couldnt have that on my conscience for the rest of my life. He needs help and all youre telling me to do is leave him. He was abused as a child and so was his mum. His whole family is fucked up. Im all hes got.
I wasnt sure where to go from here. From the outside it seemed so straightforward. Leave, run away, start again. Julia had a lot going for her. She could have a whole new life. It clearly isnt this straightforward as there are thousands of women like Julia who dont leave or run away or start again. I would never really understand the complexities of Julias violent relationship but one thing was very clear. When she said that Andy had nobody else, what she was really saying was that she didnt have anyone else. She was alone and, however difficult and abusive her relationship was, she clearly felt that it was all she had.
I was feeling guilty now. Initially, I hadnt really been taking Julia seriously. I had thought that she wanted her boyfriend sectioned because they had had a tiff. It was now clear that things were more complex. Deep down Julia knew that I wasnt going to section Andy but she was crying out for help and somehow it was me who was expected to provide this help. At medical school I had learnt about the role of mitochondrial antibodies in primary biliary cirrhosis and the parasympathetic nerve distribution to the salivary glands. It wasnt the greatest preparation for dealing with a vulnerable desperate woman who got beaten up every day by the man who supposedly loved her. Regardless of my lack of training, at that moment I was all she had and I had to do my best.
If you leave him and he harms himself, thats not your fault.
Is that the best you can do? He needs help.
Andy was a patient at another practice and I had never met him. I couldnt really speculate what he needed but psychotherapy is usually our get-out clause when faced with a difficult psychological issue that is complex and not fixed with a tablet.
Maybe psychotherapy would help Andy?
Julia looked hopeful until I explained that there was a two-year wait for psychotherapy in this town.
Thats really useful, thanks a lot.
You have to leave him, I said again. I tried to say it with compassion but I really did feel it was her only option. Julia got up, left and slammed the door. I clearly hadnt handled that very well. I had failed again. Would another doctor have handled that better? What would a counsellor have said, or a priest or even bloody Jeremy Kyle? I was not sure if Julia would come back to see me. If she did, maybe next time Id just listen.
Good doctors
What makes a good doctor? I seem to remember being asked something like this during my medical school interview. The interview panel yawned through my contrived answer that mentioned some naïve nonsense about being caring and good at working in a team. As part of our target-based existence, the patient plays a large role in deciding if we are good doctors or not. The Labour government introduced patient satisfaction questionnaires as part of our performance targets.
During my training year I saw a middle-aged woman with stomach pains. I was very concerned and referred her urgently to the hospital because I thought she might have stomach cancer. She was seen and investigated within a week and turned out to simply have bad indigestion. When the snotty letter came back from the consultant, I was feeling a little red in the face. I had made an inappropriate expensive referral to the hospital and had caused unnecessary anxiety to the patient. I could just imagine the consultant grumbling into his endoscope as he cursed me for adding to his already busy day.
The patient and her husband, however, thought the sun shone out of my arse. That wonderful Dr Daniels arranged for me to be seen so quickly. She bought me a very nice bottle of single malt to say thank you and told anyone whod listen how fantastic I was. My poor medical judgement earned me a rather nice bottle of whisky and if my patient got to fill in one of the patient satisfaction questionnaires, Id have been reported as the best doctor in the world.
Most medical practitioners have an idea whether theyre being good or bad doctors. On a Friday afternoon when Im drained and tired, I know that Im not giving my all. I try my best to remain professional but have to admit that I find it that bit harder to resist inappropriate requests for hospital referrals, sick notes and antibiotics. As GPs, we are supposed to be the gatekeepers of the NHS but sometimes it can feel much easier to leave the gate permanently ajar rather than carefully defend the NHS hospital waiting lists by fending off the worried well. Im very popular with my patients on a Friday afternoon because they are getting what they want, but Im not always practising good medicine. Making the patient happy isnt always the same as being a good doctor.
When I started as a GP I was told that it was easy to be a bad GP but hard to be a good one. A good doctor wont prescribe antibiotics for a cold and wont refer every patient with a headache for an expensive MRI scan. A good doctor should also be able to explain to the patient why hes not agreeing to their demands, but sometimes, however hard you try, the patient leaves feeling dissatisfied and the doctor goes home feeling distinctly unpopular. It is a difficult balance to run on time but give each patient adequate individual attention, to allow patient choice but not give in to inappropriate demands, to keep referral rates low but make sure the patients get the expert input they need. Im still not sure exactly what a good doctor is, but it is certainly more complex than earning a few smiley faces on a government questionnaire.
Connor
Its my kids, Doctor. Theyre little fuckers. I cant control em no more. Somethings gotta be done about it. My youngest, Connor, was brought home by the police the other day.
How old is Connor?
Hes three.
I rack my brains trying to think what a three-year-old could possibly do to get himself in trouble with the police.
They caught him putting rubbish through the neighbours letter boxes.
Was he out on his own? I ask incredulously.
Oh no, Doctor, Bradley and Kylie was with him, but they was the ones telling him to do it.
I skim through the notes to see that older siblings Bradley and Kylie are six and seven, respectively.
Mum Kerry is actually very likeable. She is a stereotypical council estate mum. Only 25, but already has three kids with three different men who are all now nowhere to be seen. Life is hard for her and she has very little support. She genuinely wants the best for her kids and really wants help.
Unfortunately for her, the entirety of my knowledge on child behaviour comes from having watched a couple of episodes of Supernanny on TV. Ive never been the sternest of people and given the way my cat walks all over me, Im probably not the best person to ask about discipline.